Inspection on 10/07/08 for Josephine Butler

This inspection was carried out on 10th July 2008.

CSCI found this care home to be providing an Poor service.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 12 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Josephine Butler 20/04/10

Josephine Butler 04/02/10

Josephine Butler 25/03/09

Josephine Butler 19/09/07

Josephine Butler 17/05/06

Josephine Butler 20/01/06

Josephine Butler 27/07/05

Josephine Butler 15/12/04

Josephine Butler 23/09/04

Josephine Butler 14/04/04

Josephine Butler 17/06/03

Extracts from inspection reports are licensed from CQC, this page was updated on 28/09/2008.

CARE HOME ADULTS 18-65 Josephine Butler 34 Alexandra Drive Liverpool Merseyside L17 8TE Lead Inspector Mike Perry Unannounced Inspection 10th July 2008 10:00 Josephine Butler DS0000025114.V366551.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Josephine Butler DS0000025114.V366551.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Josephine Butler DS0000025114.V366551.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Josephine Butler Address 34 Alexandra Drive Liverpool Merseyside L17 8TE 0151 727 7877 F/P 0151 727 7877 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mr Harold Smith Philip David Wade Care Home 21 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (21) of places Josephine Butler DS0000025114.V366551.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category/ies of service only: Care home with nursing - Code N to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: Mental disorder, excluding learning disability or dementia - Code MD The maximum number of service users who can be accommodated is: 21 Date of last inspection 19th September 2007 Brief Description of the Service: Josephine Butler House is a large detached property set in its own grounds in the Sefton Park area of Liverpool. It is short walk from Sefton Park, Lark Lane, shops, pubs and public transport. The home provides care and personal support to younger people between the ages of 18-65 years that have mental disorder. The accommodation is provided on three floors with the communal areas: lounge, dining room, conservatory, games room and quite room on the ground floor. All the service users’ accommodation is provided in single bedrooms. Service users are able to access the first and second floor by the passenger lift. The home is staffed twenty-four hours a day by a Registered Mental Nurse and support workers. The service users are encouraged by staff to access various community facilities and to maintain their independence. The manager for the service is Phil Wade and the Registered Provider is Mr Harold Smith. The weekly fee is currently £450 per week and service users are given written terms and conditions showing what is included in the weekly fee. Josephine Butler DS0000025114.V366551.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 0 star. This means the people who use this service experience Poor quality outcomes. This was an unannounced inspection that lasted ten hours over two days. During this time residents in the home were spoken to and members of staff on duty as well as the registered manager. The inspector also met with a representative of the Provider. A visiting social worker was also consulted. Prior to the visit the manager completed a pre inspection information document annual quality assurance assessment [AQAA], which provided evidence of the daily running of the home. A sample of service users care plans and risk assessments were inspected as well as staffing and other health and safety records. Also a tour of the building was made and all day areas and some [not all] resident’s bedrooms were seen. The inspector was accompanied for the 3 hours on the first day of the inspection by an ‘expert by experience’. This is a person who has had previous experience with care services as a user and who can make observations and talks to both staff and residents and provide valuable feedback to the inspector. What the service does well: During the inspection we observed one prospective resident visiting for the day and learnt that this would be increased to a weekend and then a full week. Over this period assessments are completed so that a picture can be built up of the person and the home can be better assured of meeting the care needs. Care files seen also contained assessments from referring agencies such as social services. All of the resident’s manage his or her own finances to various degrees. One residents care plan seen details the management of personal allowance with the support of staff and these arrangements were seen on the inspection. Josephine Butler DS0000025114.V366551.R01.S.doc Version 5.2 Page 6 There is a relaxed feel to the home and we observed residents to be ‘at home’. Residents make decisions about maintaining contact with their family and choose level of participation in community activities or activities in the home. Residents advised us that friends and family are welcome in the home. The registered manager organises monthly service users meetings so that residents can raise any issues in a group forum. All residents spoken to state that staff were approachable and would listen to their concerns. The general environment is very relaxed and sociable and this was observed throughout. The care plans detail the needs and input from both health care professionals and carers in the home. A visiting social worker was spoken with and felt that the staff generally promoted both good personal and health care. Residents were referred appropriately and reviews were maintained. Resident’s generally appeared clean and well presented and the dignity of residents was therefore enhanced. Staff spoken to during the inspection were enthusiastic about the home and had again demonstrated a clear interest in the resident group. The general comments received from residents were positive about the staff and found them to be supportive. What has improved since the last inspection? Of the eight requirements and 10 recommendations made on the last inspection report only two have been addressed to any degree. There is now a locked cupboard for any medication received into the home so that this can be kept safe until checked and put into the medication cabinet. Following the last inspection a decoration and maintenance plan for the home was produced aimed over a three-year period. Some work has been completed such as decorating of some bedrooms, as well as work to the roof. Some of the rendering to the front of the building has also been painted. Josephine Butler DS0000025114.V366551.R01.S.doc Version 5.2 Page 7 The staff records have improved. These were well organised and the required checks necessary to ensure new staff are fit to work with vulnerable people are now made [this had been a previous requirement]. What they could do better: The home produces a service user guide, which provides information about the home. Some of the information needs to be updated such as the address of the Commission for Social Care inspection [CSCI] listed under the complaints process. The manager should review the current guide in its entirety to ensure accuracy. It is recommended that care plans should be rewritten regularly as the aims and objectives may change and it is also useful at these times to go over the plan in some detail with the resident concerned. The plans are written in very medical terms and as these are shared with residents we would advise more descriptive care planning which highlights the ‘effect’ of such disability on the daily life of the person and how care interventions can assist the person to adapt or how any barriers can be removed. Observation during the inspection and discussion with resident’s and staff showed that resident’s make decisions over their daily lives to varying degrees. The ‘weekly planner’ is one example that could be used more constructively however in terms of getting residents to forward plan their week as opposed to the current use as merely a document that care staff complete retrospectively following the completion of an activity. The use of the ‘planner’ by staff highlights the paternalistic and ‘protective’ element to the care in the home. Some of the care practices highlighted in the report around choice regarding bathing and lighting should be reviewed. At least two residents have risk assessments around the use of the bath due to risk of scalds from hot water although the introduction of thermostatic controls would lessen the need for staff intervention and promote more independence This was a discussed at the previous inspection and has not been actioned. Resident’s are responsible for maintaining their bedrooms with the support from their key worker to encourage they maintain daily living skills. Generally speaking the residents feel supported in this although some we saw had clearly had no input on regular basis. For example one room had clearly not been cleaned for some time. Residents reported that staffing had improved and was more consistent but there are still days when there are not enough staff to consistently maintain these programmes. Josephine Butler DS0000025114.V366551.R01.S.doc Version 5.2 Page 8 There are areas of care where the independence of residents could be encouraged further. These include facilities for residents to make drinks as well as access to laundry facilities. Currently, the service does not contribute towards service users holidays and this should be given some consideration. Discussion with some residents indicates that this would be important in terms of the overall quality of life. Most of the shortcomings identified by residents and staff around quality of life issues are blamed on the ownership of the home in that funds are not made available. Residents reported that the garden is not accessible to them. The access to a garden is important for resident’s quality of life and this needs to be addressed with perhaps some fencing securing space for residents. Discussion with residents indicated a large divergence of opinion regarding the food provided at the care home. The general menu seen was very basic and lacked variety so that choice is therefore limited. Some residents commented that the meals have no fresh vegetables. Others commented that there was poor quality and cheap meals such as soup and sandwiches, egg on toast etc where very common midday. The menu seen confirmed this. This should be reviewed and addressed. Although some of the previous recommendations and requirements around the administration of medicines have been met such as improved storage there are still issues with recording and auditing processes that need to be addressed. One complaint about an aspect of the service was responded to by the manager but this was outside the time scales of the homes complaints process and this caused the complainant some frustration. Future complaints should be managed within reasonable timescales. There has been very limited staff training on abuse awareness and both staff and the manager had limited awareness of the processes to follow and this should be improved so that residents can be further safeguarded. From the inspection there remain concerns around the ability of the provider to maintain and upgrade the fabric of the building. Some evidence for this is: • Internally the building can be very dark. The normal light switches have been replaced with ones that can only be turned on and off by staff using a key. This must cease and be reversed as it infringes on the independence of the residents in the home as well as being a risk factor. One resident commented [again] that there have been instances of stumbling down the stairs. This was made a requirement on the last inspection and has not been addressed. Josephine Butler DS0000025114.V366551.R01.S.doc Version 5.2 Page 9 • Although accessible to residents none of the bathrooms are fitted with thermostatic controls to control the water temperature at a safe level. From the perspective of both safety and promoting independence the water should be regulated at a safe temperature with thermostatic valves and routinely checked. There were signs that the maintenance programme in the home is still not meeting needs in terms of maintaining standards. For example many of the bedrooms that had been identified on the last inspection had carpets that were badly stained, particularly around the sink area. Some rooms were in need of upgrading as the windows were in a very poor state of repair with flaking internal paintwork and decayed external frames. The maintenance cover for the home is currently one person three days per week and the evidence would suggest that this is in sufficient to maintain the building to an acceptable standard. Some bedrooms were not clean. For example windowsills and sinks that were stained and windows that were dirty [internally]. Again these were reflected on the last report and, although improved on this visit overall, remains an issue. On this visit some of the communal areas were not clean. We observed numerous areas [corridors, toilets] where there was debris and staining to floors and toilet basins etc. There is only person employed for this duty and there is therefore normally no week end cover or cover for holidays / sickness. Given the size of the building we felt that this needs reviewing and sufficient domestic cover arranged. Residents do not use the large garden at the rear of the home as the owner’s dogs use this space. It is apparent that some residents are anxious about going outside the home and some only go out with staff escort. There is therefore a real need for this outside facility to be made accessible and safe for residents to enjoy. • • • • It is a requirement that an improvement plan is again formulated, which includes upgrading, and maintenance plans with improved time scales for completion. We saw the duty rota for the home and there were at least seven occasions over the previous month where there had only been two staff in total on duty. This has a detrimental effect on the ability to carry out consistent care. On one occasion a residents hospital appointment was nearly cancelled and only occurred when the Community nurse was able to escort the resident. The management reported that the ability to cover the staffing rota was limited due to funding and that all requests had to be agreed by the provider. Ancillary staff cover consists of a maintenance person working three days, one domestic for 5 days who also has laundry duties and a cook who works daily Josephine Butler DS0000025114.V366551.R01.S.doc Version 5.2 Page 10 unit 17.30. The comments in the inspection report previously need to be considered with respect to sufficiency of ancillary cover. The application form for new staff does not include a list of previous work history. This is important as the recruitment process should check any spaces in work history as well as ensure a reference from previous care work even if the applicant has not worked in the care sector for some time. At the inspection the manager reiterated this: ‘training is a difficult area as I have no budget and therefore little control in organising this’. There has been limited progress since the last inspection and the induction programme remains inadequate, as it does not meet standards set out by ‘skills for care’. The issue of the lack of any budget for training is the key element in developing standards as there is difficulty planning properly due to uncertainty about the financial constraints. There is currently no external quality audits for the manager to gain any feedback about the service and the in-house audits, although improved, are not thorough enough to be monitoring and improving standards in key areas. The last inspection report required the provider to complete monthly audits [called regulation 26 visits] and produce a report for the manager as part of the overall quality processes in the home. These are still not being completed. The manager expresses a desire for the service to continue to improve and some areas have improved overall but these are limited and most requirements from the previous inspections need to be fully met. What are essentially financial constraints are the main barriers to improvements. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Josephine Butler DS0000025114.V366551.R01.S.doc Version 5.2 Page 11 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Josephine Butler DS0000025114.V366551.R01.S.doc Version 5.2 Page 12 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1 and 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The admission procedure at Josephine Butler would enable residents to be confident about the home being able to meet their needs. EVIDENCE: The nursing staff at the care home make an assessment of the residents’ needs both prior to admission and during the admission process to ensure that the facilities offered are suitable and staff have the necessary skills to meet the service user assessed needs. From the information obtained an initial service user plan and risk assessment is developed showing how the assessed needs of the resident’s would be met. During the inspection we observed one prospective visiting for the day and learnt that this would be increased to a weekend and then a full week. Over this period the above assessments are completed. Care files seen also contained assessments from referring agencies such as social services and this information is also used so that a full picture of the resident is built up. The home produces a ‘service user guide’, which provides information about the home. Some of the information needs to be updated such as the address of the Commission for Social Care inspection [CSCI] listed under the complaints process. Josephine Butler DS0000025114.V366551.R01.S.doc Version 5.2 Page 13 The manager should review the current documentation its entirety to ensure accuracy. Josephine Butler DS0000025114.V366551.R01.S.doc Version 5.2 Page 14 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Key Standards. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents care needs are monitored and planned safely but there should be a reflection by staff regarding some of the care practices so that greater choice and autonomy over daily life can be facilitated. EVIDENCE: The residents have detailed care plans and risk assessments showing how their assessed needs would be met and how identified risks would be minimised. The service user plans inspected showed that where possible the resident has been consulted about the content of the plan. The plans are reviewed at regular intervals and these reviews are detailed enough to track the progress of the resident over that period. There was some discussion with the manager regarding the inclusion of the resident at these reviews of the care plan and this could be evidenced in the documentation [for example a signature]. We also observed that some care plans were dated over a year ago. For example one was dated from 2005. It is recommended that care plans should Josephine Butler DS0000025114.V366551.R01.S.doc Version 5.2 Page 15 be rewritten regularly as, although detailed, the aims and objectives may change and it is also useful at these times to go over the plan in some detail with the resident concerned. The plans are written in very medical terms; for example: ‘has paranoid schizophrenia. Paranoid delusions and hostility’. As these are shared with residents we would advise more descriptive care panning which highlights the ‘effect’ of such disability on the daily life of the person and how care interventions can assist the person to adapt or how any barriers can be removed. Observation during the inspection and discussion with resident’s and staff showed that resident’s make decisions over their daily lives to varying degrees. There is a weekly activity plan, which show activities that each resident would like to do and whether it actually took place. This includes activities that the service users engage independently or with staff. This ‘weekly planner’ could be used more constructively however in terms of getting residents to forward plan their week as opposed to the current use as merely a document that care staff complete retrospectively following the completion of an activity. The manager said that this was the original intention of the form. The use of the ‘planner’ by staff highlights the paternalistic and ‘protective’ element to the care in the home. Further evidence of this is the current care practice of only giving bath towels out at the time staff prompt residents to have a shower or bath. Residents do not have the choice therefore to make that decision for themselves with asking staff for a towel. The lack of independent hot water controls [see below] also reduces choice. Again, as discussed on the last inspection, residents have no choice in turning on [or off] the light switches as staff control these with a key. Requirements to change this practice for both practical safety reasons [lack of light at times may lead to falls – one resident reported this had been the case some time ago] and for reasons of basic choice have not been actioned. All of the resident’s manage their own finances to various degrees. One residents care plan seen details the management of personal allowance with the support of staff and these arrangements were seen on the inspection. Residents also make decisions about maintaining contact with their family and the frequency and choose level of participation in community activities or activities in the home. One resident discussed the anticipated visit of his sister to the home. Other residents advised us that friends and family are welcome in the home. The registered manager organises monthly service users meetings so that residents can raise any issues in a group forum. All residents spoken to state that staff were approachable and would listen to their concerns. Some residents felt that suggestions made at meetings for trips out [for example] Josephine Butler DS0000025114.V366551.R01.S.doc Version 5.2 Page 16 were not carried through, as there was a lack of funding for this type of activity. Staff support resident’s to take responsible risks as identified in their service user plan. Some residents have kettles in their bedroom for which risk assessments have been developed to minimise risks. At least two residents have risk assessments around the use of the bath due to risk of scalds from hot water although the introduction of thermostatic controls would lessen the need for staff intervention and promote more independence [see environment for further discussion]. This was discussed at the previous inspection and has not been actioned. Staff gave an example of one resident who would, if not supervised, not be aware enough to ensure the water was at a safe temperature. All of the bath rooms are accessible at all times and therefore the risk, although already low, would be further minimised by the introduction of thermostatic controls to baths. Service users records are kept in a secure place and discussion with staff confirm that they understand the home’s policy on confidentiality of information. Josephine Butler DS0000025114.V366551.R01.S.doc Version 5.2 Page 17 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): All standards were inspected. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents enjoy many aspects of life in the home but there can be improvements made to ensure both independence and quality of life can be further improved. EVIDENCE: Resident’s are responsible for maintaining their bedrooms with the support from their key worker to encourage they maintain daily living skills. This does not extend to laundry however as staff attend to this as the laundry area in the basement is considered off limits for residents due to safety issues. Generally speaking the residents feel supported in this and the basic standard of cleanliness in residents bedrooms has improved since the last inspection although some we saw had clearly had no input on regular basis. For example one room had furniture and bedside cabinets that were not clean and a windowsill that had clearly not been cleaned for some time. Residents reported Josephine Butler DS0000025114.V366551.R01.S.doc Version 5.2 Page 18 that staffing had improved over the past 6 months and was more consistent but there are still days when there are not enough staff [see staffing] to consistently maintain these programmes. Resident’s make decisions over aspects of their daily lives, such as choosing to spend time on their own in their bedroom or in the communal areas with other service users. Resident’s spoken with enjoy this freedom and feel relaxed in the home. For example one resident said he feels safe and protected at the home, and also appreciates the company. He finds the staff very caring and reported that there hasn’t been much turnover of staff since he has been living there. He feels that he is pretty independent, and will sometimes go into town. He still feels nervous to go out on his own, and occasionally staff are available to go out with him. The general environment is very relaxed and sociable and this was observed throughout. Staff reported that some residents have attended college to improve their knowledge and skills. For example one resident has attended a computer course. Another resident discussed some of the artwork she had produced. The service is located close to shops, pubs, library, etc. Observation during the inspection showed that service users access these regularly throughout the day. The service is close to a main road where service users could access a number of buses. Most service users have a bus pass. There are areas of care where the independence of residents could be encouraged further. For example it was observed that drinks are supplied by staff at regular set intervals but there is nowhere for residents to make themselves a drink outside these times. Residents are ‘not allowed’ in the kitchen. Also, as mentioned, there are no accessible laundry facilities for residents so there is no possibility of developing any self-help skills in this area. Resident’s weekly activity sheets show that some access a range of community activities locally where they have the opportunity to meet others that do share the same disability. Currently, the service does not contribute towards service users holidays and this should be given some consideration. Discussion with some residents indicates that this would be important in terms of the overall quality of life. One resident commented that ‘it would be nice to go on holiday’. Most of the shortcomings identified by residents and staff around quality of life issues are blamed on the ownership of the home in that funds are not made available. One resident spoken with at length was pleased with the way the home had supported her regarding a past relationship and had also been supportive when this had become difficult. The manager was very aware of the issues involved. Josephine Butler DS0000025114.V366551.R01.S.doc Version 5.2 Page 19 Other residents spoke about being able to maintain friendships and family contact. Service users are provided with a key to their bedroom door to promote their privacy. There is good day space available and there is a large garden to the rear of the property. Residents reported that the garden is not accessible to them as the owner has some dogs and they are therefore not allowed out. Staff confirmed this. The access to a garden is important for resident’s quality of life and this needs to be addressed with perhaps some fencing securing space for residents. Discussion with residents indicated a large divergence of opinion regarding the food provided at the care home. There was evidence of a choice of meal being offered to service users on a daily basis but the general menu seen was very basic and lacked variety so that choice is therefore limited. Some residents commented that the meals have no fresh vegetables. Others commented that there was poor quality and cheap meals such as soup and sandwiches, egg on toast etc where very common midday. The menu seen confirmed this. Josephine Butler DS0000025114.V366551.R01.S.doc Version 5.2 Page 20 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The staff monitor service users health to ensure that their health needs are met by accessing appropriate support and advice from other health professionals when necessary but there needs to be attention paid to standards around the recording and other medication standards to ensure a consistently safe service EVIDENCE: Observation of residents showed that they require varying degrees of assistance regarding personal care ranging from ‘prompting’ to actually assisting to bathe [for instance]. These individual needs are described in the care plans and staff spoken with were knowledgeable as to interventions needed. The comments previously around choice and control over bathing should be noted. The care plans detail the needs and input from both health care professionals and carers in the home. Discussion with residents confirmed that staff are very supportive and are generally respectful and appropriate when carrying out personal care. There were some different opinions, which cited insensitve approaches by staff and these were discussed and fed back to the manager. Josephine Butler DS0000025114.V366551.R01.S.doc Version 5.2 Page 21 A visiting social worker was spoken with and felt that the staff generally promoted both good personal and health care. Residents were referred appropriately and reviews were maintained. Resident’s generally appeared clean and well presented and the dignity of residents was therefore enhanced. Some residents continue to have additional support from the Community Psychiatric Nurse and have regular review of their medication and mental health needs by the psychiatrist. Where necessary staff from the care home would accompany residents to outpatient appointment and visit to the chiropodist, optician or dentist. The nursing staff at the care home currently administers medication to the residents. Despite some discussion with the manager on the previous inspection regarding some development in residents becoming more independent with self-medication there has been no progress on this. There is no risk assessment tool for self-medication although the homes policy does talk about self-medication for residents. The home uses a monitored dosage system and records are kept of all medication received into the care home, administered and returned to the pharmacist. These records were not clear however. For example a medication record for one resident who has PRN [give when necessary medication] was inspected. Although medication had been received on 23.6.08 according to the label on the box and number of tablets on the medication record [MAR], the date had not been recorded on the MAR. This makes it difficult to do a stock audit. There was a ‘stock check’ sheet for this medicine but this was also confusing as the fore medicines had also not been entered. The running total was there fore not correct. Advice was given about entering a date on the MAR when medicine is received so that medicines can be audited. Also the stock check sheet needs to be accurate. Other medicines received on the medication records where also not dated. In addition there were handwritten entries on the records but some of these wee difficult to read and therefore open to misinterpretation, which could put residents at risk. The signatures of some staff where obscured because two were signed in the same box with the adjacent box blank. The manager has been completing regular audits of the medicines and the most recent cited ‘some gaps found where medicines not recorded’. Although the audits are picking up some anomalies they appear not robust enough to pick up others. Residents spoken with were satisfied with the way they received their medicines and said that these were always on time. Josephine Butler DS0000025114.V366551.R01.S.doc Version 5.2 Page 22 Although some of the previous recommendations and requirements have been met such as improved storage there are still issues with recording and auditing processes that need to be addressed. Josephine Butler DS0000025114.V366551.R01.S.doc Version 5.2 Page 23 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Key standards. Quality in this outcome area is Poor. This judgement has been made using available evidence including a visit to this service. Residents feel safe in the home and feel their concerns are listened to but there must be more awareness amongst both staff and management of the safeguarding procedures so that residents are fully protected. EVIDENCE: The service has a complaint procedure, which is displayed in a prominent position. The service user guide also lists the complaints procedure although the contact address for the Commission [CSCI] needs to be updated. A suggestion box is available to enable residents to raise their concerns or make comment about the service. The service has received no complaints internally since the last inspection. All residents spoken to felt safe in the home and felt that staff would listen to their concerns. One complaint received by The Commission for Social Care inspection [CSCI] concerning a personal relationship of one of the residents was referred to the service for investigation by the manager. The complaint did receive a written reply from the manager but this was outside the time scales of the homes complaints process and this caused the complainant some frustration. A second reminder was made by the inspector for the manager to respond. Future complaints should be managed within reasonable timescales. The service has various policies and procedures in place to protect service users and staff from all forms of abuse. The local safeguarding adults Josephine Butler DS0000025114.V366551.R01.S.doc Version 5.2 Page 24 procedures are situated in the office and there was evidence from staff that these have been read. There has been very limited staff training on abuse however and both staff and the manager had limited awareness of the processes to follow. The manager was not aware, for example, of the local safeguarding contact [careline]. This should be improved so that residents can be further safeguarded. Both staff and management cited lack of funding for training as a major issue in the home. Josephine Butler DS0000025114.V366551.R01.S.doc Version 5.2 Page 25 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Key standards Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. There are good advantages for residents in terms of the general layout and vicinity of the home but there needs to be better monitoring of the fabric of the building with respect to maintenance and some health and safety issues so that residents are assured of a safe and homely environment. EVIDENCE: The building has some positive attributes and is suited to the resident group in that it is in keeping with the local community most of the bedrooms are very large and the home is within a short walking distance to the local shops and public transport. All accommodation is provided in single bedrooms. Many of the bedrooms are personalised with resident belongings that reflect their interests. There are a number of toilets and bathrooms, which are located near the bedrooms and the communal areas. The communal areas in Josephine Butler are large and airy which could be used for a variety of Josephine Butler DS0000025114.V366551.R01.S.doc Version 5.2 Page 26 purposes. There is a large lounge, a smoking lounge, dining room and a games room. Since the last inspection the provider and manager have agreed an upgrading and maintenance plan for the home and some of this has been carried out in that some bedrooms have been decorated and the rendering has been painted. He roof has also had some remedial work completed [this reported by management. A representative of the provider was spoken with and said that the upkeep of the environment as whole was difficult as funds were not readily available. The three-year plan to upgrade the home was based on a realistic budget. From the inspection there remain concerns around the ability of the provider to maintain and upgrade the fabric of the building. Some observations: • The expert by experience had not visited this service before, and on arriving there was no sign on the gate or by the front door. It was only upon entering the porch that there was a notice on the inner door stating that the building was Josephine Butler. This could be an issue for new service users, and friends and family coming to visit service users. Internally the building can be very dark. The manager explained that residents continually left lights on and this has meant large electricity bills. The normal light switches have been replaced with ones that can only be turned on and off by staff using a key. This must cease and be reversed as it infringes on the independence of the residents in the home as well as being a risk factor. One resident commented [again] that there have been instances of stumbling down the stairs. This was made a requirement on the last inspection and has not been addressed. Although accessible to residents none of the bathrooms are fitted with thermostatic controls to control the water temperature at a safe level. There are risk assessments in place, which state that residents are at risk from scalds and need staff supervision for bathing. From the perspective of both safety and promoting independence the water should be regulated at a safe temperature with thermostatic valves and routinely checked. There were signs that the maintenance programme in the home is still not meeting needs in terms of maintaining standards. Many of the bedrooms that had been identified on the last inspection had carpets that were badly stained, particularly around the sink area. Some rooms were in need of upgrading as the windows were in a very poor state of repair with flaking internal paintwork and decayed external frames. The windows on the top floor room discussed on the inspection had only one of the windows that could be opened [out of three] and when we tried to open one found it to be broken and rotten. DS0000025114.V366551.R01.S.doc Version 5.2 Page 27 • • • Josephine Butler During the inspection it became apparent that there was water leaking into the basement of the building and this was taking up much of the maintenance persons time. The same bedroom on the top floor had a large damp patch in one corner indicating problems with the roof / gutter outside. Staff reported that this has had work completed but the problem still remains. The maintenance cover for the home is currently one person three days per week and the evidence would suggest that this is in sufficient to maintain the building to an acceptable standard. • Some bedrooms were not clean. For example windowsills and sinks that were stained and windows that were dirty [internally]. The key workers are responsible for maintaining bedrooms with residents and this needs to be monitored closely so that basic hygiene standards are met. Again these were reflected on the last report and, although improved on this visit overall, remains an issue. On this visit some of the communal areas were not clean. We observed numerous areas [corridors, toilets] where there was debris and staining to floors and toilet basins etc. we were advised by staff that the domestic was on holiday the week of the inspection. There is only person employed for this duty and there is therefore normally no week end cover or cover for holidays / sickness. The domestic also has laundry duties to perform. Given the size of the building we felt that this needs reviewing and sufficient domestic cover arranged. As previously mentioned the large garden at the rear of the home but residents advised us that it couldn’t be used as the owner’s dogs use this space. Staff confirmed this. It is apparent that some residents are anxious about going outside the home and some only go out with staff escort. There is therefore a real need for this outside facility to be made accessible and safe for residents to enjoy. • • Despite the advantages enjoyed by residents with the general spaciousness of the facilities these issues must be addressed by the manager and provider. The existing improvement plan for the home is clearly not addressing the issues. It is a requirement that an improvement plan is again formulated, which includes upgrading, and maintenance plans with improved time scales for completion. The ongoing monitoring of the environment should be reviewed on a regular basis and should form part of the monthly auditing visits by the provider [Regulation 26 visits]. Only three of these reports were available. Josephine Butler DS0000025114.V366551.R01.S.doc Version 5.2 Page 28 Josephine Butler DS0000025114.V366551.R01.S.doc Version 5.2 Page 29 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 32,33,34,35. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Staffing in the home is insufficient to meet care needs consistently and training needs improvement so that residents can be assured staff are competent to meet their needs. EVIDENCE: On both days of the inspection the staffing numbers were one trained nurse and two care staff for 16 residents. Generally both staff and residents reported that staffing was a little more stable over the last few months and there had not been the turn over of staff that the home had experienced previously. Conversely we saw the duty rota for the home and there were at least seven occasions over the previous month where there had only been two staff in total on duty. The manager confirmed this. Staff stated that the effect for residents care was that some of the individual personal care programmes had to be missed and that the ability to take residents out [who needed escort] was obviously diminished. On one occasion a residents hospital appointment was nearly cancelled and only occurred when the Community nurse was able to escort the resident. Josephine Butler DS0000025114.V366551.R01.S.doc Version 5.2 Page 30 Another effect could be the lack of input to assist residents in maintaining their bedrooms [see comments previously], which is reliant on sufficient key workers to both prompt and monitor standards. The management reported that the ability to cover the staffing rota was limited due to funding and that all requests had to be agreed by the provider. Ancillary staff cover consists of a maintenance person working three days, one domestic for 5 days who also has laundry duties and a cook who works daily unit 17.30. The comments in the inspection report previously need to be considered with respect to sufficiency of ancillary cover. Staff files were checked in terms of the recruitment process for the home. Of the two files inspected one did not have the required clear Protection of Vulnerable Adults [POVA] check prior to starting work in the home. The POVA check was dated after the last inspection visit, however, when this issue was first raised and was therefore an update of an existing file. The manager explained that both POVA and Criminal Record checks are now made prior to employment. All other recruitment checks were available. The application form however, does not include a list of previous work history. This is important as the recruitment process should check any spaces in work history as well as ensure a reference from previous care work even if the applicant has not worked in the care sector for some time. On the pre inspection information form given by the manager there is a statement to the effect that more training for staff is needed. At the inspection the manager reiterated this: ‘training is a difficult area as I have no budget and therefore little control in organising this’. Staff reported that the manager does some in-house sessions. These are brief but cover some mental health issues. There has also been some progress in that all staff have commenced or are due to start NVQ training although currently only two care staff out of eight have this qualification. One care staff is waiting to commence further training: ‘I can’t move onto this without completing certain mandatory training. The owners told me that the service won’t pay for any training that is not in-house, and it is this that is causing the delay’ The induction of new staff is currently very basic and both staff records and interviews confirm that the induction does not meet the induction standards set out by ‘skills for care’. This was discussed and the manager needs to audit the current induction checklist against these standards. Again this was an issue on the previous inspection. Staff interviewed were unaware of the Code of Conduct that should be issued to all care staff from the General Social Care Council [GSCC] and this needs to be included in the induction package. Josephine Butler DS0000025114.V366551.R01.S.doc Version 5.2 Page 31 The issue of the lack of any budget for training is the key element in developing standards as there is difficulty planning properly due to uncertainty about the financial constraints. The provider has not taken up the recommendation on previous inspection reports for the manager to be a given realistic budget. Staff spoken to during the inspection were enthusiastic about the home and had again demonstrated a clear interest in the resident group. The general comments received from residents were positive about the staff and found them to be supportive. Josephine Butler DS0000025114.V366551.R01.S.doc Version 5.2 Page 32 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Key standards. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The manager tries to run the home for the best interests of the residents but is restrained by limited finances from meeting some basic requirements. EVIDENCE: Phil Wade is the Homes Registered Manger. He has a nursing qualification in mental Health [RMN] and has had a long history for working in the private sector. He was manager of a care home prior to Josephine Butler. He is able to provide some evidence of managerial update over recent years by the completion of an eight-week management course [certificate seen]. Phil was doing an NVQ at level 4 management but has not completed this and it would still be recommended [manager has also identified this]. Josephine Butler DS0000025114.V366551.R01.S.doc Version 5.2 Page 33 The strength of the manager is that he provides a very good role model for the approach to care in the home and is trusted by both residents and staff alike. The home does seek out the views of the residents by holding regular resident meetings and the use of quarterly satisfaction surveys. There is currently no external quality audits for the manager to gain any feedback about the service and the in-house audits, although improved, are not thorough enough to be monitoring and improving standards in key areas [medication and environmental standards for example]. The last inspection report required the provider to complete monthly audits [called regulation 26 visits] and produce a report for the manager as part of the overall quality processes in the home. During this inspection the only reports available were from February 2007, June 2007 and March 2008. The manager expresses a desire for the service to continue to improve and some areas have improved overall but these are limited and most requirements from the previous inspections need to be fully met. The pre inspection information returned highlights some of the issues raised in this report and cites what are essentially financial constraints as the main barriers to improvements. Both the provider and manager must now address the outstanding requirements with some urgency so that standards can be improved for residents in the home. Health and safety records were inspected. The pre inspection information states that all safety certificates are up to date and some of these [fire, electricity, gas safety] were checked on the inspection visit. Josephine Butler DS0000025114.V366551.R01.S.doc Version 5.2 Page 34 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 1 ENVIRONMENT Standard No Score 24 1 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 2 33 2 34 3 35 1 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 2 X 3 X LIFESTYLES Standard No Score 11 2 12 3 13 3 14 2 15 3 16 2 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 1 X X 3 X Josephine Butler DS0000025114.V366551.R01.S.doc Version 5.2 Page 35 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA7 Regulation 13(4) Requirement Residents must be able to maintain their safety as well as maintain choice regarding the ability to control the lighting in the home; therefore current arrangements must be reviewed and appropriate light switches put in place. The external grounds at the rear of the building must be maintained and made safe so that residents can easily access them for the purpose of leisure activity. Timescale for action 01/10/08 2 YA14 23(2) (o) 01/10/08 3 YA23 13(6) 4 YA20 13(2) All management and staff must 01/10/08 have training in the management and awareness of abuse so that residents can be assured of being fully protected from any risk of abuse. The registered person shall make 01/09/08 arrangements for all medication received in to the home to be recorded accurately. [Last requirement dates 30/01/07 and 15/10/07 not met] Josephine Butler DS0000025114.V366551.R01.S.doc Version 5.2 Page 36 5 YA24 23(2)(b) The registered person shall 01/10/08 ensure the premises are of sound construction and kept in good state of repair externally and internally to provide a pleasant and safe environment in which residents can live. [Last requirement date 28/02/07, 30/10/07 not met] There must be an improvement and maintenance schedule [written] that addresses the issues listed in the report under ‘environment’ and includes completion dates. 6 YA26 16(1) (c) Suitable carpeting / floor covering must be supplied in the bedrooms of residents identified on the inspection so that they are living in acceptable and comfortable surroundings. The window in the room identified on the top floor of the home must be repaired or replaced and kept in a good state of repair and maintenance so that the resident can open and close windows easily and comfortably. Other windows must be identified for repair / replacement and entered on the maintenance programme. 01/10/08 7 YA24 23(2) (b) 01/10/08 8 YA24 13(4) (b) Both safety and independence of residents with respect to bathing must be addressed and thermostatic controls fitted to baths to reduce risk of scalds as DS0000025114.V366551.R01.S.doc 01/10/08 Josephine Butler Version 5.2 Page 37 well as promote independence for residents. 9 YA30 23(2) (d) All parts of the home must be kept clean so that residents are living in comfortable and dignified surroundings. The registered person must ensure that at all times suitable qualified, competent and experienced staff are working at the care home in such numbers as are appropriate to maintain the wellbeing of the residents so that care needs are met consistently. [Last requirement date 15/10/07 not met] 11 YA35 18(1)(c) (i) The registered person must ensure that staff receive training appropriate to the work they are to perform including structured induction training that meets current standards. [Last requirement date 30/11/07 not met] 12 YA39 26 The registered provider who is 01/09/08 not in day to day charge of the home shall visit the care home at least once a month unannounced, and prepare a written report on the conduct of the home. [Last requirement dates 28/02/07 and 30/10/07 not met] 01/10/08 01/09/10 10 YA33 18(1) (a) 01/09/08 Josephine Butler DS0000025114.V366551.R01.S.doc Version 5.2 Page 38 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard YA1 Good Practice Recommendations Some of the information in the service user guide [SUG] needs to be updated such as the address of the Commission for Social Care inspection [CSCI] listed under the complaints process. The manager should review the current documentation its entirety to ensure accuracy. We observed that some care plans were dated over a year ago. For example one was dated from 2005. It is recommended that care plans should be rewritten more regularly. The manager should reflect on some of the care practices in the home which can reduce choice and control for residents including: • • • • 4 YA11 Use of medical terminology in the care plans Use of the weekly planner Bathing arrangements control of lighting. 2 YA6 3 YA7 There are areas of care where the independence of residents could be encouraged further: • It was observed that drinks are supplied by staff at regular set intervals but there is nowhere for residents to make themselves a drink outside these times. There are no accessible laundry facilities for residents so there is no possibility of developing any self-help skills in this area. • 5 YA14 The planning and support of residents [including financial] to engage in a holiday should be seriously considered so that residents can experience and learn from social activity external to the home. The key worker support of residents in terms of DS0000025114.V366551.R01.S.doc Version 5.2 Page 39 6 YA16 Josephine Butler maintaining the standard of cleanliness in their bedroom needs to be more targeted and consistent 7 8 YA17 YA20 The menu is very basic and lacks real choice and quality. This should be reviewed. All residents should be assessed in terms of ability to self medicate and a suitable risk assessment should be used for any resident who wishes to self medicate. It is recommended that some written feedback be requested from the supplying pharmacist when carrying out the auditing visits to the home. All medicines prescribed need to be easily read on the MAR chart. The manager, on all medication standards, should carry out thorough routine internal audits. 9 10 YA22 YA23 Future complaints should be managed within reasonable timescales. There needs to be more in depth and external training available for staff so that awareness of safeguarding issues and reporting of allegations of abuse is more clearly understood. NVQ training in the home should continue and meet the standard of at least 50 care staff trained. A copy of the code of conduct issued by the General Social Care Council [GSCC] should be given to all care staff. The staff application form does not include a list of previous work history. This is important as the recruitment process should check any spaces in work history as well as ensure a reference from previous care work even if the applicant has not worked in the care sector for some time. 13 YA35 The registered person should ensure that the registered manager has a training budget to enable them to prioritise staff training and ensure that all staff have an ongoing training programme appropriate to the work that they are to perform. The registered person should complete their NVQ level 4 Management qualifications to satisfy the National Minimum Standards of 2001. DS0000025114.V366551.R01.S.doc Version 5.2 Page 40 11 12 YA32 YA34 14 YA37 Josephine Butler 15 YA39 In the absence of any external quality audits there should be thorough internal audits [particularly around medicines and environmental standards] so that continued monitoring and improvement can be evidenced. It is highly recommended that a professionally recognised quality audit system be employed in the home so that there is continuous self-monitoring of the service. Josephine Butler DS0000025114.V366551.R01.S.doc Version 5.2 Page 41 Commission for Social Care Inspection Merseyside Area Office 2nd Floor South Wing Burlington House Crosby Road North Waterloo, Liverpool L22 OLG National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Josephine Butler DS0000025114.V366551.R01.S.doc Version 5.2 Page 42 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!